An appeal to Rep. Jayapal to Maintain the Integrity of HR 676

The letter below was sent priority mail in early December to Representative Pramila Jayapal at both her Seattle and Washington, D. C. Offices. We are awaiting a response. We urge others to write and call (202-225-3106) to encourage Rep. Jayapal to make public the draft of her new Medicare for All bill and to maintain in her bill all the elements of the model single payer bill, HR 676, including the ban on for-profit nursing homes, hospitals, dialysis centers and other institutions.

We thank you for your efforts to promote a new campaign for national single payer Medicare for All legislation.

We have been working at all levels of the union movement since 2003 to build support for HR 676, Expanded and Improved Medicare for All. Currently over 600 union organizations, including 157 Central Labor Councils and 44 State Federations, have endorsed HR 676. HR 676, based on the proposal of the Physicians for a National Health Program, is a sound, integral whole which, when enacted, will bring universal care to the U. S. while reining in the costs.

While we applaud your activism around HR 676, we must express our deep concern with your announcement that you are re-writing the bill and using S 1804, the Senate Medicare for All bill, as the model. The opposite is what must be done: S 1804 should be re-written to include all the vital elements of HR 676.

S. 1804 is missing a number of parts crucial to a single payer bill and includes some things, such as Section 611 (b), that will destroy its effectiveness. We are at the beginning of raising up a powerful movement in the country that makes passage of HR 676 possible. It is so important that the model, evidence-based bill, HR 676, remain intact as the foundation for that movement.

Here are the ways in which S. 1804 falls dangerously short of being an effective single payer bill, and we ask that you keep HR 676 as the model single payer bill by not adding any of these S 1804 items.

1. S 1804 leaves long term care to the states under Medicaid, whereas HR 676 bring it under the national Medicare for All program. Abandoning long term care to the states means that it will continue to be means-tested. People will have to become impoverished in order to be eligible. The rules and care will vary from state to state leaving the fragile elderly and disabled dependent on state budgets that are continually being cut.

2. S 1804 allows the for-profit hospitals, nursing homes, dialysis centers, and investor-owned facilities to continue to exploit patients. Research shows that the investor-owned entities have both lower quality care and higher costs. That’s why HR 676 wisely transforms the system to remove the for-profit providers, and this crucial part must be kept in HR 676. This transition away from profit is not only affordable but may even save money.

3. Unlike HR 676, S 1804 does not provide for global budgeting I e. lump sum payments to each hospital and other institution to cover operating expenses. That budgeting would eliminate per-patient billing and free up the wasted dollars to be used for care. Without this budgeting, and the separation of operating from construction costs, the Medicare for All bill will not be financially viable.

4. While S 1804 has removed most copays and deductibles, it keeps a copayment on certain drugs. HR 676 does not. Copayments have been proven to deprive patients of necessary care and are detrimental to health. HR 676 must be kept free of any payments at the point of service.

5. Unlike HR 676, S 1804, in section 611 (b), adopts the payment systems of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Affordable Care Act basing physicians’ and other payments on an unworkable, unfair, and wasteful system supposedly rated according to value. The crude measurements vastly increase administrative costs, shift physician attention away from patients, exacerbate physician burn-out, and punish the providers who serve minority and less healthy and wealthy communities.

These “value based payment” systems were recently condemned by Karen Joynet Maddox, MD, MPH, cardiologist and health services researcher in an article in JAMA. “We are literally taking money from providers that serve the poor and giving it to providers that serve the rich,” she said.

As if that were not bad enough, these payment systems in S 1804 cost more when the finances for their implementation are included.

The application of these payment systems to hospital readmissions is not working to save money nor patients. According to a 2018 study, penalties imposed on hospitals with excess readmissions of congestive heart failure patients led to a reduction in such readmissions yet an increase in patient deaths!

In addition, and just as bad, the Accountable Care Organizations that are set up under these payment systems shift risk to providers and open a back door to the re-entrance of the insurance companies to continue undermining our single payer system.

7. Unlike HR 676, S 1804 inserts supposedly incremental steps of public options and Medicare buy-ins for four years prior to arriving at a real single payer plan. Because S 1804 expands care while maintaining the private insurance companies, costs will skyrocket before the savings of single payer kick in. The incremental steps will become a roadblock rather than a path to single payer. Perhaps the worst part of this inclusion of the public option and the Medicare buy-in is the reinforcement of the false notion that there should or must be transitional steps to single payer. Neither the public option nor the Medicare by-in are based on sound policy. To place them in the bill for even a short period of time endangers the single payer goal.

We respectfully ask that you maintain the integrity of HR 676 and do not import these harmful sections of S 1804. We would support adding to HR 676 the ban on the application of the Hyde amendment to health care funds.

We welcome discussion on these ideas and would be happy to meet with you to further examine these vital issues. Upon request, I can provide any sources needed for items in this letter.